GUIDELINES FOR ORGAN DONOR MANAGEMENT

The following are recommendations only and are not intended to replace clinical judgment

***For any potential Organ Donor please page the Organ Donation Resource Nurse(ODRN) 506-643-6848***

GENERAL MONITORING
  • Vitals q1h
  • Continuous Central Venous Pressure monitoring
  • Continuous Arterial Line Pressure monitoring
  • Continuous EKG and pulse oximetry monitoring
  • Urine Catheter to straight drainage – Strict intake and output
  • Nasogastric tube to straight drainage, unless receiving enteral feeding

GENERAL TARGET
  • Temperature 36 – 38 o
  • Heart Rate between 60 – 120 beats per minute
  • Systolic Blood Pressure between 100mmHg -160mmHg
  • Mean Arterial Pressure (MAP) greater than or equal to 70mmHg
  • CVP 6 – 10mmHg (normovolemia)
  • Urine Output 0.5 – 3ml/kg/HR
  • Hgb greater than or equal to 70, optimal target greater than or equal to 90
  • Blood Glucose 4 – 8 mmol/L
  • SpO2 greater than or equal to 95%
  • Normalized Na, Ca, PO4, K, Mg

GENERAL NURSING CARE
  • Blood glucose by glucometer Q1H (if stable Q2H, then Q4H)
  • Turn and position Q2H
  • Routine suctioning and PRN

VENTILATOR ASSOCIATED PNEUMONIA (VAP) PREVENTION
  • Oral care and decontamination with Chlorhexidine
  • Elevation of the head of bed at 45 degrees when possible, otherwise greater than 30 degrees
  • Utilization of endotracheal tubes with subglottic secretion drainage

GLYCEMIA AND NUTRITION
  • Initiate and titrate insulin infusion to maintain serum glucose 4-8mmol/L
  • Initiate or continue enteral feeding as tolerated (VAP Prevention). Discontinue on call to the OR
  • Continue parenteral nutrition if already initiated

DONOR EVALUATION
INITIALLY
  • Electrolytes, urea, creatinine ,HCO3, glucose, Ca, Mg, PO4, Uric acid, ALK, BILT&D, GGT, AST, ALT, LDH, CK, Amylase, Lipase, Troponin, Lactate, CBC, PT/PTT, INR, non-fasting lipid profile, Albumin, serum osmolality
  • Type and Screen (hold 4 units on call to OR)
  • Urinalysis – Routine and Micro
  • Urine C&S, Sputum for C&S, Blood Cultures X 2 (2 sets – one peripherally, one from existing line) *identify all cultures as Organ Donor*
  • CXR
  • EKG

Q4H
  • ABG, electrolytes, HCO3, glucose, urea, creatinine, PT/PTT, INR, BILT&D, AST, ALT, ALK, GGT, CK, LDH, Lipase, Amylase, Lactate

Q8H
  • CBC, Mg, Ca, PO4

Q24H
  • Repeat blood, urine and sputum cultures, CXR

□ FOR HEART DONOR
  • 12 Lead EKG then Q24H
  • Troponin Q12H
  • Echo (cardiac) – Cardiology consult if necessary for Echo interpretation

□ FOR LUNG DONOR
  • ALVEOLAR LUNG RECRUITMENT Q2H:
□Step 1.Increase FiO2 to 1.0
□Step 2.Increase PEEP to 30 cmH2O
□Step 3.Maintain PEEP at 30 cmH2O for 30 seconds
□Step 4.After 30 seconds, return all ventilation to initial settings for two minutes, leaving FiO2 at 1.0
□Step 5.Repeat recruitment maneuver as per above (Steps1-3)
  • After each Recruitment Maneuver proceed with LUNG CHALLENGE
  • O2 LUNG CHALLENGE Q2H:
□Step 1.Set PEEP to pre-recruitment level, FiO2 to 1.0, ventilate for 20 minutes
□Step 2. Obtain Arterial Blood Gas after 20 minutes; Goal: PaO2 greater than 300 mmHg
□Step 3. Once ABG drawn, return ventilation to pre recruitment/challenge settings

  • Repeat Lung Recruitment and Lung Challenge including ABG Q2H until either the Organ Donation Resource Nurse states to stop recruitments or until patient goes to the operating room for organ retrieval.

  • Chest physio
  • Chest X-Ray Q24H and PRN
  • Bronchoscopy with bronchial washings gram stain and culture
  • Ventilate targets:
Tidal volume 8-10 ml/kg, PEEP 5 cm H20, (PIP) less than or equal to 30 cm H20
SaO2 greater than 95%
PH 7.35 – 7.45
PaCO2 35–45mmHg
PaO2 greater than or equal to 80mmHg
□FOR CORNEA DONOR
  • Flush eyes well with Balanced Salt Solution (one bottle per eye)
  • Instill eye drops of a broad-spectrum antibiotic. Ex: Optimycin or Polysporin eye drops, ½ bottle (5cc) in each eye
  • Tape the eye shut using paper tape. Tape from eye brow covering eyelash to cheek
  • Fill two (2) small bags with ice and place directly over taped eyes. Wrap head with gauze to keep wet packs in place. DO NOT WRAP TIGHTLY.

MEDICATIONS
COMBINED HORMONAL THERAPY
  • Vasopressin infusion: if not already started, should be initiated for all donors. May consider giving 1 unit IV bolus followed by an infusion. Starting dose: 0.6 -2.4units/hr (0.01-0.04 units/min) **maintain this infusion unless SBP greater than 160mmHg**
  • Levothyroxine (T4) 100mcg IV bolus followed by 50mcg IV bolus Q12H
  • Methylprednisolone 15mg/kg (up to a max of 1 gram) IV Q24H

FOR HYPOTENSION – For a systolic blood pressure less than 100mmHg
  • 1st choiceVasopressin infusion: up to 2.4units/hr(0.04 units/min) IV infusion. Starting dose: 0.6 - 2.4units/hr(0.01-0.04 units/min) **maintain this infusion unless SBP > 160mmHg**
2nd choice □ Norepinephrine IV infusion (titrate to effect – caution with doses greater than 0.2 mcg/kg/min)
Other choices
□Epinephrine IV infusion (titrate to effect – caution with doses greater than 0.2 mcg/kg/min)
□Phenylephrine IV infusion (titrate to effect – caution with doses greater than 0.2 mcg/kg/min)
□Dopamine less than 10mcg/kg/min IV infusion
FOR HYPERTENSION – For a systolic blood pressure greater than 160mmHg.
  • Wean and/or discontinue inotropes first followed by Vasopressin.
If necessary start:
□Nitroprusside 0.5 to 5 mcg/kg/min IV infusion
□Esmolol 100 – 500 mcg/kg IV bolus followed by 100 –300mcg/kg/min IV infusion
FOR DIABETES INSIPIDUS – Defined as: urine output greater than 4ml/kg/hr associated with
  1. rising serum Na greater than or equal to 145 mmol/L and/or
  2. rising serum osmolality greater than or equal to 300 mmol/KG and/or
  3. decreasing urine osmolality less than or equal to 200 mmol/KG.

DIABETES INSIPIDUS THERAPY – Titrate therapy to urine output less than or equal to 3ml/kg/hr.
If not already started, should be initiated for all donors
  • Vasopressin infusion: up to 2.4units/hr IV infusion. Starting dose: 0.6 -2.4units/hr **maintain this infusion unless SBP > 160mmHg**
Then if needed:
□DDAVP 1 – 4mcg IV followed by
□DDAVP 1 – 2mcg IV Q6H prn
Prevention of contrast media-induced renal failure:
□Acetylcysteine 150 mg/kg in 500 mL NS over 30 minutes immediately before contrast media injection followed by 50 mg/kg in 500 mL NS over 4 hours after contrast media injection OR
□Acetylcysteine 600 mg or 1200 mg IV before contrast media injection followed by 600 mg or 1200 mg orally twice daily for 48 hours after contrast media injection (total of 3000 mg or 6000 mg)

REFERENCES:

Canadian Council for Donation and Transplant (2004). Medical management to Optimize Donor Organ Potential: A Canadian Forum

Horizon Health Network – Zone 1 Moncton, Policy & Procedure Manual (2009).CORNEA PREPARATION FOR RETRIEVAL. 4.5.7.

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Form # OD-15-03 (12/2017)